If you choose to provide your name/contact information, it will be held in the strictest confidence. If you opt not to provide your name/contact information, rest assured that your concern will be investigated. Make a Report (*) is a required field. First Name Last Name Phone Email Address *Please select the topic closely related to your concern: Select Billing and Coding Issues Conflict of Interest Discrimination Emergency Medical Treatment and Active Labor Act (EMTALA) Matters Gifts and Entertainment Harassment Misconduct or Inappropriate Behavior Patient Abuse (Physical, Verbal Mental, Sexual) Patient Care Patient Rights Physician Payment and Referral Concerns Privacy/Confidentiality Safety, Health and the Environment Substance Abuse Theft Violence/Threats Other Location where incident occurred *Please provide a detail description of your concern. Include any information that could be valuable in the evaluation and resolution of your concern. Please provide the approximate timeframe in which your concern occurred: Is management or your direct supervisor aware of your concerns: Select Yes No What is your relationship to Thibodaux Regional Health System? Select Employee Contractor Medical Staff/Allied Health Other Do you wish to remain anonymous for this report? Select Yes No Attach any additional information that you feel would be helpful in addressing your concern. Submit 29.7810152000000000 -90.8054270000000000 Thibodaux Regional Health System Eric DeGravelle, Compliance Officer 985.493.4722